Case Study 43 Choledocholithiasis

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  • Topic: Liver, Common bile duct, Pancreatic duct
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Case Study 43 Choledocholithiasis
Scenario
T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the ED for evaluation. After orienting him to the room, call light, bed controls, and lights, you perform your physical assessment. The findings are as follows: he is awake, alert, and oriented (AAO) \3, and he moves all extremities well (MAEW). He is restless, is constantly shifting his position, and complains of (C/O) fatigue. Breath sounds are clear to auscultation (CTA). Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm (RRR). Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. A sharp inspiratory arrest and exclamation of pain occur with deep palpation of the costal margin in the RUQ (positive Murphy’s sign). He reports light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. Skin and sclera are jaundiced. Admission vital signs (VS) are 164/100, 132, 26, 36° C, SaO2 96% on 2 L of oxygen by nasal cannula (O2/NC).

What structures are located in the RUQ of the abdomen?

The primary structures that are located in the RUQ are the Liver and the Gallbladder. Other structures included are sub-structures of the afore mentioned, the ones worth mentioning for this case questions given the patients condition are the common bile duct and the duodenum.

Which of the above mentioned organs are palpable in the RUQ?

Most if not all of the normal liver is concealed by the right rib cage and is beyond the feel of a examiner's hand. The normal liver is smooth, with no irregularities. When the liver can be felt, it is usually due to: (1) increased diaphragmatic descent; (2) presence of a palpable caudate or Riedel's lobe; (3) presence of emphysema with an associated depressed diaphragm; (4) thin body habitus with narrow thoracic cage; (5) fatty infiltration (enlarged with rounded edge); (6) active hepatitis (enlarged and tender); (7) cirrhosis (enlarged with nodular irregularity); or (8) hepatic neoplasm (enlarged with rock-hard or nodular consistency). The Gallbladder is palpable using the Murphy's technique and can help determine both cholecystitis and or choledocholithiasis.

CASE STUDY PROGRESS
T.B.’s abdominal ultrasound (US) demonstrates several retained stones in the common bile duct (CBD) and a stone-filled gallbladder. T.B. is admitted to your floor, NPO status, and is scheduled to undergo an endoscopic retrograde cholangiopancreatogram (ERCP) that afternoon. While the patient is sedated, the ERCP scope is inserted through the mouth and extends past the stomach to the outlet of the CBD, the ampulla of Vater. Typically this muscle will be cut to widen the opening and outflow of the CBD, a procedure called a sphincterotomy. This allows the bile and stones (cholesterol or pigmented) to flow out into the small intestine.

Given T.B.’s diagnosis, what laboratory values would be important to evaluate?

A liver function blood test should be ordered for T.B. because it can show an elevation in bilirubin and serum transaminases. Other indicators include raised indicators of ampulla of vater (pancreatic...
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